ABout two months ago, I began having facial pains-stabbing (right cheek and behind the right eye). My face would turn red near my right cheekbone and my right ear would also become red. During this time, I also began having neck/back pain, numb arm and leg, and my middle and ring fingers do not separate unless I make an attempt to separate them-all pain is on the right side. I had an MRi and CT scan of the brain-all negative. I was diagnosed with a facial neuralgia and began taking indomethacin. This seemed to help with the facial pain and neck/back pain. I was also diagnosed with iritis(inflammation of the iris) which can be idiopathic or a sign of an autoimmune disease/arthritis. Since I had so many problems, I was tested for multiple automimmune diseases-all negative. Recently, I had an MRI of the cervical spine. It revealed that there was a mild disc bulge at C5-6 contributing to mild overall spinal canal stenosis and mild narrowing of the left lateral recess. Since my family doctor ordered this MRI, I have not learned much about what these results mean. Can someone help explain this to me? I was also wondering if these results could cause any of the pains that I have been experiencing? (I have also been tested for the genetic marker (HLA-B27)for ankylosing spondilitis, but I have not received the results yet.)

I am curious why your doc thought you might have this?

C5-6 Disc (C6 nerve root)
Cervical Disc Disease Cervical Disc Herniation


Epidemiology:

C5-C6 represents 90% of cervical disc lesions


Anatomy:

Lateral herniation compresses the nerve root below
Example: C5-6 disc herniation compresses C6 root


Pathophysiology: Nerve Impingement Types

Acute Cervical Disc Herniation (younger patients)
Soft disc protrusion from nuclear herniation
Chronic Cervical Disc Disease (older patients)
Hard disc lesion associated with Cervical Spondylosis


Symptoms:

Neck tight or stiff
Provocative
Worse with activity
Worse on awakening in Morning
Worse with neck extension
Worse with coughing, sneezing, or straining
Referred pain
Radiation into shoulder
Radiation along Radial Nerve distribution into arm
Does not often radiate below elbow
Contrast with Paresthesias (distal radiation)
Radiation into medial scapula
Interscapular pain is not of shoulder origin

Associated symptoms:

Headaches
Dysphagia
Related to large anterior osteophytes


Signs:

Decreased Range of Motion
Neck flexion and extension
Neck lateral bending to right and left
Neck rotation to right and left
Neck hyperextension elicits pain
Pain on palpation
Localized C-Spine tenderness
Trigger Point tenderness over interscapular area
Vertex Compression Test (Spurling Test)
Turn neck to ipsilateral side and axial load
Pressure against top of head reproduces arm pain
Sensory Exam
Often not helpful

Signs:

Pain
Neck
Shoulder
Medial scapula
Dorsolateral arm
Sensory change
Dorsolateral thumb
Index finger
Motor weakness and atrophy
Biceps muscle
Extensor pollicis longus
Reflexes decreased
Biceps reflex
Brachioradialis reflex

Management:

See Cervical Disc Herniation Management
Conservative management indicated in most cases
See Cervical Disc Herniation Rehabilitation
No danger in observation
Encourage patience
Do not rush surgical intervention
Surgery (5% of cases)
Indications
Pain and Disability intolerable
Arm pain responds better than neck pain
Major neurological deficit
Procedure: affected disc replaced
Bone graft
Arthrodesis
Results
Arm pain subsides immediately after surgery
Osteophytes in foramen absorbed in 9-18 months

http://spinetalk.conforums.com/index...num=1159682717

Prognosis:
Most patients improve with conservative management
Recovery may require weeks to months

What does ankylosing spondylitis mean?

Ankylosing means fusing together. Spondylitis indicates inflammation of the vertebrae. Both words come from the Greek. So, AS describes the condition by which some or all of the joints and bones of the spine fuse together. Entire fusing of the spine is unusual. Many people will only have partial fusion, sometimes limited to the pelvic bones. - return to top

What exactly is AS?

AS is a painful, progressive, rheumatic disease. It mainly affects the spine but it can also affect other joints, tendons and ligaments. Other areas, such as the eyes, lungs, bowel and heart can also be involved. - return to top

What actually happens?

Inflammation occurs at the site where certain ligaments or tendons attach to bone (enthesis). This is followed by some erosion of bone at the site of the attachment (enthesopathy). As the inflammation subsides, a healing process takes place and new bone develops. Movement becomes restricted where bone replaces the elastic tissue of ligaments or tendons. Repetition of this inflammatory process leads to further bone formation and the individual bones which make up your backbone, the vertebrae, can fuse together. The pelvis is commonly affected first. The lower back, chest wall and neck may also become involved at different times. - return to top

Is ankylosing spondylitis the same as spondylosis?

No. They sound similar but they are different. Spondylosis is a term relating to "wear and tear" and is more common in older people. AS relates to an inflammatory condition which produces new bone and leads to fusion. The vigorous exercise therapy designed for people with AS might be harmful to those suffering from spondylosis. - return to top

Is AS common?

AS affects approximately 1 in 200 men and 1 in 500 women in Britain. - return to top

Who gets AS?

Men, women and children can all suffer from AS. It typically strikes people in their late teens and twenties, with the average age being 24. However, symptoms can start at other periods of life. AS is more common in men, with nearly three times as many men having it as women. - return to top

Is AS different in men, women and children?

Yes. AS tends to affect men, women and children in slightly different ways. Men: The pelvis and spine are most commonly affected. Other joints which may be involved are the chest wall, hips, shoulders and feet. - return to top

Women: Involvement of the spine is generally less severe than in men. The pelvis, hips, knees, wrists and ankles are the most commonly involved. Children: It is unusual for a child under the age of 11 to develop symptoms of AS. The joints which are typically affected first are the knees, ankles, feet, hips and buttocks. They rarely suffer from back pain. In youngsters, AS may lead to persistent hip disease ultimately requiring a hip replacement sometime in adult life. - return to top

What are the symptoms of AS?

Typical symptoms of AS include:

Slow or gradual onset of back pain and stiffness over weeks or months, rather than hours or days.
Early-morning stiffness and pain, wearing off or reducing during the day with exercise.
Persistence for more than three months (as opposed to coming on in short attacks).
Feeling better after exercise and feeling worse after rest.
Weight loss, especially in the early stages.
Fatigue.
Feeling feverish and experiencing night sweats. - return to top
Does AS affect other joints?


Yes. AS sometimes causes aching, pain and swelling in the hips, knees and ankles. Indeed, any joint can be affected. In most cases the pain and swelling will settle down after treatment. It is particularly important to stretch the hip joint to prevent stiffening in a bent position making you lean forward. The heel bone can become particularly troublesome causing pain in two areas. Most common is the under surface, about three centimetres from the back of the foot. This is called plantar fasciitis and can last for many weeks. It may respond to an insole for the shoe designed to take weight off that part of the heel. The less common pain arises at the back of the heel where the Achilles tendon is attached to the heel bone. Pressure from the shoe may aggravate the pain. - return to top

Does AS affect other organs?

Yes. AS can sometimes affect the eyes, heart and lungs. These effects are not life-threatening and they can be treated with relative ease. - return to top

How does AS affect the eyes?

AS can cause inflammation of the iris and its attachment to the outer wall of the eye, the uvea. 40% of people will develop iritis or uveitis on one or more occasions. Usually the first symptom is a slight blurring of vision in one eye but the main symptom is a sharp pain together with a dramatically bloodshot eye. To avoid permanent damage you should receive prompt treatment. It is a good idea to go straight to a casualty department, rather than to your GP, where you can be treated by an ophthalmology team. Tell them that you have AS. They will give you eye-drops which will reduce the inflammation in a matter of hours. Continue treating yourself with the eye-drops for as long as the inflammation persists. - return to top

How does AS affect the heart?

Very occasionally AS can have a mild effect on the heart. In most cases this is so mild that it is difficult to detect. AS may cause the aortic valve to leak. More commonly, though, it affects the conduction of electrical activity within the heart. Usually any such problems are unnoticed by the person with the condition. - return to top

How does AS affect the lungs?

AS should not make you any more susceptible to lung or chest infections. However, it may affect the rib joints and the muscles between the ribs making breathing, sneezing, coughing or yawning painful. As a result, the lungs fail to become fully ventilated. You will find some advice in the exercise section of this booklet to help you maintain normal chest wall movement. Sometimes the lungs may get scarred, a condition know as apical pulmonary fibrosis. This will show up on an X-ray but does not usually cause any symptoms. In the late stages of AS the chest wall may become quite fixed and affect air entry in and out of the lungs. This does not mean you stop breathing! The diaphragm muscle continues to work and your stomach moves in and out as you breathe. Large meals and tight clothing will increase the effort of breathing so you may find it more comfortable to avoid these. It is also vital to avoid smoking since this will not only make breathing more difficult but it could cause potentially serious lung and chest infections. - return to top

Does AS affect everybody the same way?

No. AS is a very variable disease. Some people have virtually no symptoms whereas others suffer more severely. However, at NASS we know that those patients who follow an appropriate course of exercises tend to do better than those who don't. - return to top

Will I need surgery ?

It is unlikely. Surgery plays a very small part in the management of this condition. About 6% of people with AS need to have a hip replaced. This will successfully restore mobility and eliminate pain of the damaged joint. In rare cases surgery is used to restore a straighter posture of the spine and neck to people who have become severely stooped. - return to top

What medication will I need?

Over 80% of people with AS take non-steroidal anti-inflammatory drugs (NSAID) to reduce inflammation and relieve pain and stiffness. However, some people may experience side-effects with NSAIDs and prefer to take simple pain killers such as paracetamol. For others, especially those who suffer from inflammatory bowel disease (Crohn's disease and ulcerative colitis) or peripheral joint arthritis, a disease-modifying antirheumatic drug like sulphasalazine may be required.

Re: What is Ankylosing spondylitis?
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ANTI-TNF

In the last few years readers of AS News have followed the reports in the developments of a new form of treatment for some rheumatic diseases, including ankylosing spondylitis. These are called TNF blockers or anti-TNF drugs and two of them have now received a Europe-wide license. They were first used in rheumatoid arthritis (RA) simply because there are more RA sufferers than AS, therefore, not unnaturally the first trials were on patients with rheumatoid arthritis.

Over the last few years, trials in Europe and North America, based on treatment regimes as set out in the manufacturers' recommendations, have been conducted on the use of these biologic agents for ankylosing spondylitis and a few other rheumatic diseases. These trials have demonstrated conclusively, that in many cases, there are both clinical improvements and in a few studies, improvements in Magnetic Resonance Imaging (MRI) parallel to the clinical improvement. The evidence suggests that there is reason to suspect that in AS, the drug is even more effective than it is in RA, especially as it is recognised that AS has a limited response to anti-inflammatory drugs.

The first to be issued with a European-wide license in 2003 was Remicade produced by Schering-Plough. This drug is delivered to the patients, in hospital, by infusion over a two-hour period, approximately every six weeks. The second drug, Enbrel was licensed for AS in 2004 and is manufactured by Wyeth and is delivered twice a week by self-injection subcutaneously (beneath the skin). The drugs, therefore, being delivered to the patients own home every few weeks. These medications can, in the UK, only be prescribed by rheumatologists, and their use will be severely limited by the health authorities because they are exceedingly expensive and the long-term effects are not yet known. This expense relates to long scientific development time and the fact that they are made by a biological method which is slow and costly. Because of this cost topic, many Primary Care Trusts (PCT) in this country are at the moment resisting its use, or not increasing the hospitals drug budget to take the additional costs into consideration. There is, however, direct evidence of postcode prescribing in rheumatoid arthritis, so we predict there could be the same problems in AS. Some PCTs are claiming that they are not obliged to provide the medication for people with AS as the National Institute for Clinical Excellence, NICE, has not yet passed these drugs for this indication: it will not look at it until 2005 and make their announcement in 2006. However they are wrong, as there was a health service circular, HSC/1999/176, which stated that the fact that NICE had not approved the drug was no reasons for it being withheld, when the physician is of the opinion that it should be used. This was confirmed in the House of Lords on 3rd April 2001 by the then Parliamentary Under-Secretary of State. The reason why there were questions in the House at that time, was because it was licensed to be used in RA and NICE had not at the time reviewed it. This is exactly the situation where AS is today, three years later.

There is undoubtedly a cost effective case to be made in favour of its use when one considers those patients who have such severe disease, that they either are, or more importantly, about to lose their occupations because of their disease severity. In addition, there are considerable days, sick leave lost per year, in many of the employed AS population. Research so far indicates that very few working days are lost after the commencement of anti-TNF treatment. By balancing the cost to the state in social security benefits, against the cost of using the medication, the case is made for its use. In addition, one should take into consideration the possible surgical implications, sometimes associated with severe disease. There is, for example, spinal surgery in a small number of patients, as well as hip replacement in 6% of the AS population. There are also a number of other surgical problems such as knees and jaw joint replacement, a number of which could probably be avoided with the appropriate use of anti-TNF. There can, in many cases of AS, be considerable additional costs in treating some of the well-known side effects, mainly gastrointestinal, associated with non-steroidal anti-inflammatory agents.

The British Society for Rheumatology (BSR), in the last few months of 2003 and in the first few months of 2004, held regular meetings of a working party to produce guidelines for prescribing anti-TNF blockers in adults with ankylosing spondylitis. As the Director of NASS, I was privileged to be on that working party. The other ten members are all experienced in the management of patients with AS and have a familiarity with the use of TNF blocking agents. All of the research papers that had been published over the last three years, up until that date, were reviewed and their findings collated and recommendations added. The report which followed was presented at the BSR annual meeting which was held in April 2004. We are awaiting a response from their rheumatology colleagues and when that has been received and noted, the final recommendations will be published in one of the main rheumatology journals.

However, basically the recommendations are that everybody should be tested and treated for the TB germ if they have previously had TB or in contact with other people who have had the disease. This is because, in very few cases, there is evidence that TB has been reactivated as a result of this treatment. It is recommended that pregnant women should not be treated but this is only a precaution, as nothing is known. Also people with active significant infection, as well as certain types of heart complications, and certain types of disease process affecting the central or peripheral nervous system should all be excluded. All patients must meet the modified New York criteria for AS, after taking reasonable measures to ensure that the symptoms are not due to alternative causes such as spinal fracture, disc disease and fibromyalgia. The doctor must also be of the opinion that all other forms of medication have failed, which includes anti-inflammatory drugs and disease modifying agents, such as methotrexate. The patient must also have reached a score of more than 4 on what is known as the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and spinal pain score during the previous week, measuring more than 4 on the Visual Analogue Scale (VAS).

Fortunately, beneficial effects have also been noted in Crohn's disease, when associated with AS, as well as in cases of psoriasis, where separate guidelines have been drawn up. Some observers have also noticed that there seems to be a beneficial effect on osteoporosis, a condition which can also be associated with AS, even at a young age. It looks that by switching off the inflammatory process, there is an increase in bone formation. This means that anti-TNF may make a contribution to a reduction of spinal fracture in later life. There is no evidence yet to suggest that uveitis or iritis benefits. However, as the above conditions frequently overlap with AS, it means that some patients can have two or three conditions benefiting from the same treatment.

The report also includes circumstances under which the drugs are withdrawn, examples being when there are severe, adverse effects, and inefficacy indicated by a failure of the BASDAI score to improve by 50% or a fall by more than 2 units, and VAS to reduce by 2 units, after three months of therapy.

It is not yet known if there is an appropriate time to withdraw the medication and what the effects are. However, one study has suggested that 64% of cases flared, which means that one-third did not flare after withdrawal.

The BSR are encouraging all rheumatologists to log the names of all patients on TNF, with their patients permission. This is known as the British Society for Rheumatology Biologics Registry (BSRBR), and reports regularly during the course of treatment. This would allow them to pick up quickly on any adverse reactions, not already known, especially as any long-term downstream consequences are not yet known. This reporting is in addition to the existing practice known as the Yellow Card system. The working party recognises that, as further evidence becomes available, the guidelines will be reviewed and revised periodically. This, therefore, means that the information on this website might change from time to time. There is, for example, a third manufacturer whose anti-TNF drug may also be available for treating AS within the next two years. - return to top

What causes AS?

We're not entirely sure. So far medical research has shown that 96% of people with AS in Britain all share the same genetic cell marker - Human Leucocyte Antigen B27 (HLA-B27). It is possible that some normally harmless micro-organism, which on this occasion the immune system cannot fight, comes into contact with HLA-B27 and sets up an adverse reaction. Sometimes bowel infections appear to spark off AS. Symptoms may also become apparent after a period of enforced bed rest, for example following a car accident, accelerating a previously existing mild condition. A group of symptoms known as Reiter's Syndrome may also lead to AS. These include iritis (or uveitis) which is inflammation of part of the iris; and conjunctivitis which causes red, gritty and painful eyes. People with Reiter's Syndrome also suffer from urethritis. This is inflammation of the urethra, the tube that conveys urine from the bladder out of the body. This results in pain on passing urine, discharge on the end of the thingy (especially on waking up in the morning) and an increased frequency of passing urine. Women may get the pain but won't notice a discharge from the urethra. Reiter's Syndrome also results in arthritis, affecting the large joints, especially in the legs, together with pain in the joints of the lower back particularly at night or on waking. - return to top

What is the risk of passing it on to my children?

If a parent has AS there is a 50% chance that the B27 gene will be passed on to a child. However, not everyone with the B27 gene will go on to develop AS. Overall, the likelihood of your child developing AS will be less than 1 in 10 (or 1 in 5 if B27 positive). The chance of a child inheriting the condition from a grandparent will be less than 1 in 20. Should your child develop early symptoms of AS, it is advisable to ask your GP for a referral to a rheumatologist. - to top

Are any other diseases associated with AS?

A skin condition called psoriasis is associated with AS. Psoriasis causes scaly patches on the skin and scalp. It can also lead to a slightly different form of arthritis. A sexually acquired infection known as Non-Specific Urethritis (NSU) can be caused by an organism called chlamydia. This leads to urethritis and sometimes other features of Reiter's Syndrome. Ulcerative colitis or Crohn's disease are also related to AS but are not caused by it. The symptoms are bouts of bloody diarrhoea, often with fever, weight loss, and an associated peripheral arthritis in some cases. - return to top

How can I be sure I have AS?

If you have the classic symptoms of AS, your GP will look at your posture to see if the lumbar spine is losing the forward curve and beginning to flatten out. If so, the GP will probably refer you to a rheumatologist who will study X-rays of your spine and look for characteristic changes to the joints in the lower back. Unlike other rheumatic conditions, blood tests are not very helpful for diagnosing AS. - return to top

Is there a cure for AS?

Alas, there is not! Anti-inflammatory drugs will help to reduce pain and improve your sleep and general well-being. But drugs are only half the answer. Appropriate exercise is crucial to managing your AS. The drugs should enable you to carry out these exercises with less pain. You will find some of these exercises later in this booklet. - return to top

What is the end result?

AS seems to affect everybody slightly differently. In general, though, you will probably find that the symptoms come and go over many years. In the classic case, the lumbar spine can become stiff, caused by the growth of additional bone, as can the upper spine and neck. If you pay attention to your posture, exercise regularly and avoid the stoop associated with the condition, you can prevent this from becoming too serious. - return to top

The Spine

The spine is made up of 24 vertebrae and 110 joints. There are 3 sections: 7 cervical, 12 dorsal or thoracic and 5 lumbar vertebrae. The cervical, or neck section, is the most mobile. In the thoracic section each vertebrae has a rib attached to it on each side. Below the lumbar section is the diamond-shaped sacrum which locks like a keystone into the pelvis. The joints between the sides of the sacrum and the rest of the pelvis are called the sacroiliac joints. This is usually the starting-point of the condition where the low back pain and AS begin. More Spine Info... - return to top

Ankylosing Spondylitis has been brought up by my neurologist, family doctor, and opthamologist. I believe that they all mentioned AS because I was having lower back pains and was having problems getting out of bed in the morning-real stiff. I am 28 years old and AS seems to present itself with younger people. Also, the opthamologist mentioned it because I had iritis which is often associated with certain diseases-one of which is AS. I have been dealing with these issues for two months now, and I am starting to get really FRUSTRATED. My family doctor didn't really stress, even though I asked, whether or not the bulging discs, spinal stenosis, and lateral recess narrowing, could cause this type of pain(back, arm, neck, leg pain). The facial pain and headaches were HORRIBLE-not as bad now with the indomethacin. I have an appointment to see my neurologist on 11/27, but I have two-three doctors appointments a week since the facial/pain headaches have started. I have not been able to work, and I can tell that my family doctor is ready to send me to work soon. I would love to return to work, but I am in such pain some days that I don't know how I will make it through an entire work day. My family doctor even mentioned whether I was starting to feel "down" and whether I think I'm in more pain than I am. I know this can happen to people, but I love life, and I am still in good spirits despite the frustration of a lack of diagnosis.

Hilary,

It can be very frustrating trying to find the cause of our pain. Do not give up or get depressed. Sometimes it requires us searching and seeing many doctors. I saw doctors into the double digits until I found one I was really comfortable with and allowed him to do the surgery.

My RA doc just assigned the reading on AS to me as well. I am much older than you, but have spinal problems throughout my entire spine. I also have a grandfather that I think suffered with this disease.

Dermatomes of the spine....







Hope this helps you to understand better....

Thanks so much GJZH for the information and the encouragement. I guess I just feel like I have been left in the dark with this entire situation. I finally get to see my neurologist on 11/27 after a month of receiving my MRI results, so everything that I have learned about interpreting my MRI results has been through the internet. It will be nice to actually hear information from my doctor to determine what are the next steps for me. I am currently taking indomethacin which does help me to function. However, I have been told that I can not remain on this because of stomach issues that this medicine may cause. This worries me because I literrally can not function without this medicine-due to the neuralgia and pain from head to toe. I just hope that there is some solution for me. I would really like to return to a "normal" life.

I don't know much about either, but it looked from reading what you wrote on the mri, that all it was saying was that disc disease doesn't seem to be major, nor does arthritis.

Please read the attached link at Round Earth Publishing. Your symptoms seem to match some of the pain and dysfunction pattterns of the Strenocleidomastoind muscle and asociated myofascial trigger points.
http://www.round-earth.com/SCM.html

Also look at the Head and Neck Pain at: http://www.round-earth.com/HeadPainIntro.html

Good Luck.

Thanks for the information "painfree!" Some of the symptoms are similar to the way that I feel, but I'm just not sure if this could be the problem. However, it has definitely been a struggle to diagnose what the issue could be, so I guess this is possible.

Hi, Hilary,

I'm just curious: Have any of your doctors ordered the HLA-B27 lab test?

I have AS. There are certain "hallmark" indicators that flag docs toward differential dx. One is, as you stated, iritis. In many, too, symptoms may be, initially, within the SI joints.

Have your doctors ruled out/in Trigeminal Neuralgia?

Bobbi,

I actually just had the test for the genetic marker HLA-B27 a few days ago. I just received the results, and it was negative. Trigeminal Neuralgia is what the neurologist thought was the problem with my face since I had so much facial pain (stabbing pain.) However, my arm/leg have both been going numb, and I have back pain and a terrible pain at the base of my head. Thank goodness, that the medicine has helped with all this, but it seems as though it is just masking the pain not solving the problem. Just curious, how common would it be for someone to have AS without the genetic marker. I know that this would strongly suspected to be the problem at one point due to the lower back pain (hip area) and the iritis, but maybe the back pain is simply from the bulging discs/spinal stenosis.